The nation’s largest post-acute care advocacy group is raising red flags about federal regulators’ efforts to get a handle on growing hospital costs by creating quality measures based on payment outcomes for “elective” knee and hip surgeries.

The American Health Care Association (AHCA) says it is “concerned” by the lack of detail in (admittedly early) discussions of outcomes measures designed to rein in spiraling Medicare bills for knee and hip replacement surgeries. In comments to the Centers for Medicare & Medicaid Services (CMS), AHCA says it worries that “patient access to such services may be compromised.”

Even worse, AHCA says, “hospitals may become dis-incentivized to perform necessary [but] elective [hip or knee surgeries] on patients with clinical factors that have not been adequately risk-adjusted.”

In an effort to move toward a bundled payment system that many hope will save Medicare dollars, CMS has posted two separate, white paper-style briefings on the development of risk-adjusted quality measures, which some fear could ultimately penalize hospitals that treat more complex (and therefore, more expensive) hip and knee surgeries, as well as post-acute rehabs. The agency has asked for public comment on the reports, both of which broadly analyze cost patterns in 30- and 90-day episodes.

But AHCA says the reports seem to be missing crucial questions about how patients, once operated on, get back to full health.

AHCA members aren’t directly affected by the current discussion, but for Ciolek and others, that’s all the more reason to get regulators to focus on the entire spectrum of care. Particularly worrisome, Ciolek suggests in his five-page letter to federal regulators, is that CMS’ experts apparently haven’t looked broadly enough at the variety of ways hip or knee patients are getting into the operating rooms in the first place, or what happens once they leave surgery.

The worry is that if hospitals can be penalized for patients who require extended rehabilitation (as seems probable in knee or hip surgeries for those patients with complex needs), then doctors and hospitals will either avoid the surgeries in the first place or not send patients to proper outpatient rehabilitation. Either way, Ciolek argues, people may suffer needless pain, or have chronic functional difficulties, because they won’t be allowed to get better.